"Change in Ownership/Operation for Underground Storage Tanks" - Mississippi

Change in Ownership/Operation for Underground Storage Tanks is a legal document that was released by the Mississippi Department of Environmental Quality - a government authority operating within Mississippi.

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STATE OF MISSISSIPPI
CHANGE IN OWNERSHIP/OPERATION FOR UNDERGROUND
STORAGE TANKS
For USTs in
(state use only)
Return
Mississippi Dept. of Environmental Quality
Office of Pollution Control – UST Branch
Completed
ID # _________________
MS
Form
P.O. Box 2261
Date
Recorded: ____________
To:
Jackson, MS 39225
Instructions
This form must be completed and submitted within 30 days of becoming new owner or operator of underground storage tanks (USTs)
Type or print in ink all items except “signature” in Sections I. and VII.
The new owner/operator’s signature and the old owner/operator’s signature is required for this form to be valid.
I. Previous Ownership/Operation
Previous Owner/Operator Name
Signature of Previous Owner/Operator
Date Signed
II. Ownership of Tanks
III. Location of Tanks
New Owner Name
Facility Name
MDEQ ID Number
Mailing Address
Physical Address (P.O. Box not acceptable)
City
State
Zip Code
City (nearest if not within city limits)
State
Zip Code
MS
Phone
Fax
County
Phone
E-mail
Fuel Brand (BP, Exxon, Shell, etc.)
Indicate Total
Number of
USTs at
this location
NOTE: If any changes to the UST system have occurred during
Will you participate in the Compliance Assistance Program (CAP) to
ownership/operation transfer, you must complete a Notification for
provide you with reminders of upcoming testing requirements?
☐ Yes
Underground Storage Tanks form.
No
IV. Contacts
Each facility is required to have a trained UST Compliance Manager (Class A/B Operator). Include the UST Compliance Manager and other
facility contacts.
UST Compliance Manger
Phone
Email
Mr.
Ms.
Other Contact
Phone
Email
Mr.
Ms.
VI. Financial Responsibility
Select a method showing how you have met the financial responsibility requirements in accordance with UST-2 Subpart H.
 State Trust Fund (motor fuel tanks only)
 Self Insurance
 Private Insurance
 Guarantee or Surety Bond
VII. Certification
(Read and sign after completing all sections.)
I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents,
and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information
is true, accurate, and complete.
Name and Title of UST Owner (type or print)
Signature of UST Owner
Date Signed
Mr.
Ms.
Produced by the Mississippi Department of Environmental Quality, Office of Pollution Control, Underground Storage Tank Branch
P.O. Box 2261, Jackson, MS, 39225; (601) 961-5171 Phone; (601) 961-5093 Fax; www.mdeq.ms.gov
2020
STATE OF MISSISSIPPI
CHANGE IN OWNERSHIP/OPERATION FOR UNDERGROUND
STORAGE TANKS
For USTs in
(state use only)
Return
Mississippi Dept. of Environmental Quality
Office of Pollution Control – UST Branch
Completed
ID # _________________
MS
Form
P.O. Box 2261
Date
Recorded: ____________
To:
Jackson, MS 39225
Instructions
This form must be completed and submitted within 30 days of becoming new owner or operator of underground storage tanks (USTs)
Type or print in ink all items except “signature” in Sections I. and VII.
The new owner/operator’s signature and the old owner/operator’s signature is required for this form to be valid.
I. Previous Ownership/Operation
Previous Owner/Operator Name
Signature of Previous Owner/Operator
Date Signed
II. Ownership of Tanks
III. Location of Tanks
New Owner Name
Facility Name
MDEQ ID Number
Mailing Address
Physical Address (P.O. Box not acceptable)
City
State
Zip Code
City (nearest if not within city limits)
State
Zip Code
MS
Phone
Fax
County
Phone
E-mail
Fuel Brand (BP, Exxon, Shell, etc.)
Indicate Total
Number of
USTs at
this location
NOTE: If any changes to the UST system have occurred during
Will you participate in the Compliance Assistance Program (CAP) to
ownership/operation transfer, you must complete a Notification for
provide you with reminders of upcoming testing requirements?
☐ Yes
Underground Storage Tanks form.
No
IV. Contacts
Each facility is required to have a trained UST Compliance Manager (Class A/B Operator). Include the UST Compliance Manager and other
facility contacts.
UST Compliance Manger
Phone
Email
Mr.
Ms.
Other Contact
Phone
Email
Mr.
Ms.
VI. Financial Responsibility
Select a method showing how you have met the financial responsibility requirements in accordance with UST-2 Subpart H.
 State Trust Fund (motor fuel tanks only)
 Self Insurance
 Private Insurance
 Guarantee or Surety Bond
VII. Certification
(Read and sign after completing all sections.)
I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents,
and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information
is true, accurate, and complete.
Name and Title of UST Owner (type or print)
Signature of UST Owner
Date Signed
Mr.
Ms.
Produced by the Mississippi Department of Environmental Quality, Office of Pollution Control, Underground Storage Tank Branch
P.O. Box 2261, Jackson, MS, 39225; (601) 961-5171 Phone; (601) 961-5093 Fax; www.mdeq.ms.gov
2020